Strategic Communication Framework for Hormonal Contraceptive Methods and Potential HIV-Related Risks Beth Mallalieu October 22, 2015
SHC vs. SBCC Strategic health communication (SHC) and social and behavior change communication (SBCC) are used interchangeably to: Maintain positive (healthy) individual behaviors and social norms and conditions Create an enabling environment for the adoption of positive (healthy) behaviors and social norms. Create demand for available health services
What is a communication strategy? A communication strategy is a tool for guiding the development of all communication products and activities for a given project. provides everyone with guidance on what is to be achieved and how to go about getting there through a complementary set of mutually reinforcing products and activities harmonized towards a shared vision of change
Why do we need a communication strategy? To ensure that: Project goals, objectives, roles and responsibilities are clear to all partners and implementers The activities and tools selected are best for achieving goals given the available resources Targets, and milestones are clear to enable monitoring and evaluation of efforts
Why do we need a communication strategy? To ensure that: Beneficiary audiences and their needs are clear Messages are correct, consistent across board and tailored to meet specific audience needs Available resources are properly allocated among all agreed activities
Why Do We Need Communication on HC and HIV? Evidence is not straightforward Progestogen-only injectable contraception, particularly DMPA, has been linked in some studies, but not others, to an increased risk of HIV acquisition What does this mean for women? How do providers orient women?
Quick Review of WHO MEC No restrictions on the use of any hormonal contraceptive method for women living with HIV or at high risk of HIV. Clarification added: women using progestogen-only injectable contraception should be strongly advised to also always use condoms, male or female, and other HIV preventive measures. Country teams and providers are facing challenges in how to understand and implement this clarification to the MEC. Underscored need for strategic communication guidance
Communication Challenges Post MEC Groups urged WHO to develop guidance on helping women and providers understand risk for informed decision making WHO convened 2 consultations to grapple with issues: Protecting women s right to have children Balancing risks to protect health Protecting women s right to informed FP choice Reducing maternal & infant risk WHO & USAID asked HC3 to develop guidance
Purpose of Strategic Communication Framework Tool Aims to guide local efforts to communicate the risks and benefits of hormonal contraceptives among women at risk of, or living with, HIV in an easy-to-understand and comprehensive format. Provides a roadmap for country adaptation with key audiences, suggested messages & activities/channels. Not one size fits all model--a foundation to be adapted and expanded upon by countries to create national/ subnational communication strategies tailored to the local context Ensures communication activities and outputs are coordinated to achieve agreed-upon goals and objectives..
Steps in Developing a Communication Strategy 1. Situational Analysis 2. Audience Segmentation 3. Strategic Design a. Audience Profile b. Communication objectives c. Positioning d. Key messages e. Strategic approaches and activities 4. Monitoring and evaluation
1. Situational Analysis Problem Analysis: What is the problem? What are it s immediate and remote causes. Can it be solved through communication? People Analysis Whom does this problem affect? Who influences them? Who else (gatekeepers etc.) will be needed to address this problem?
1. Situational Analysis cont. Context analysis: What knowledge do they have? How do they receive info? What new info do they need? What motivates people to act? Do they have the ability to act? What are their core values? Social and cultural norms? Wider structural issues?
Illustrative Content of a Communication Strategy for Country Adaptation Part 1: Situation Analysis Country teams should gather existing data and disaggregate it by age, sex, geographic location and other important variables to help understand the current scenario. Teams should also engage as many stakeholders as possible to develop a comprehensive understanding of their context. USAID, WHO, and other implementing partners already have existing data that can be used, such as DHS surveys or other population- based surveys. The data should help answer the following questions: Epidemiological Context What is the HIV prevalence? What is the maternal mortality? What proportion of women currently use a modern contraceptive method? Among women using modern contraception, what proportion use each specific method, such as injectables or condoms? Is information available on how consistently condoms are used in the country? What country data exists around condom use with different partners (e.g., regular partners, spouses, casual partners outside of marriage, female sex workers, etc.)? What gaps exist in the data and what are the plans to gather that information? Useful Data Sources Demographic and Health Surveys (DHS) http://www.measuredhs.com/data/ UNAIDS http://www.unaids.org/en/dataanalysis/ WHO http://www.who.int/research/en/ UN World Contraceptive Use http://www.un.org/en/development/desa/ population/publications/dataset/contracept ion/wcu2012.shtml
2. Audience Segmentation Break audiences into sub-groups with defined and similar characteristics. Do this for primary and influencing audiences Primary: the key people to reach with messages, usually those most at risk or directly affected by the issue Influencing: people who impact or guide the knowledge and behaviors of the primary audience.
Part 2: Audience Segmentation- Illustrative Content Primary and Secondary Audience Segments (with Rationale for segment selection) Primary Audience 1: Sexually active women of unknown status or who are HIV- negativeusing or considering using progestogen- only injectables. Rationale: Women need all available information about the potential risks of HIV acquisition associated with progestogen- only injectables, even if the evidence is not yet conclusive. Primary Audience 2: Sexually active women living with HIV, including those on ART, using or considering using a method of hormonal conception. Rationale: HIV- infected women need all available information about various methods of hormonal contraception and how these do or do not influence the risk of HIV transmission to men, HIV disease progression, and potential drug interactions with ART. Primary Audience 3: Health system managers (MOH unit heads, health facility directors, district health leaders, etc.) Rationale: This group is responsible for ensuring national guidelines and communication interventions are implemented at the facility and community levels. Primary Audience 4: Clinical service providers (public and private) Rationale: This audience segment provides direct counseling, family planning, and HIV services to women and their partners. Providers often influence women s contraceptive options and choices. They need to understand the WHO medical eligibility criteria for contraceptive use, including the recent 2012 clarification for women at high risk of HIV who choose progestogen- only injectables. Clinical service providers need to be able to communicate this information to their clients. Primary audience 5: Non- clinical service providers (community health workers, etc.) Rationale: Community outreach workers orient couples, families, and communities on health behaviors, and provide family planning methods in some countries (typically injectables, oral contraceptive pills, and condoms) and refer clients to family planning and HIV services. They often live in the community they serve and are a first line of advice to their peers.
Primary and Secondary Audience Segments (with Rationale for segment selection) Influencing Audience 1: Male partners of women of reproductive age Rationale: Men play a key decision- making role in couple communication for family planning, condom use, child spacing, HIV prevention, treatment and sexual risk behavior. Also, HIV- negative male partners in sero- discordant couples may be at risk for HIV acquiring HIV from their female partner, while HIV- positive male partners in sero- discordant couples may be at risk of transmitting HIV to their female partner. Influencing Audience 2: Civil society stakeholders in HIV, family planning and women s health, and empowerment programs (NGOs, CBOs, etc.) Rationale: Activists and interest groups function as watchdogs in many societies for women s rights in health and play a critical role in advocacy. Influencing Audience 3: Media/journalists Rationale: Journalists may convey facts about emerging data to policy makers, civil society stakeholders, community leaders as well as citizens through popular news formats such as radio and TV programs. They have the potential to communicate and/or miscommunicate information about the relationships between different methods of HC and various HIV- related risks, including the potential risk of HIV associated with progestogen- only injectable contraception.
3. Strategic Design Audience Profile Communication objectives Positioning Key messages Strategic approaches and activities These steps are completed for every audience
3. Strategic Design cont. Audience Profile Highlights the characteristics of the audience Helps guide the messages and activities to ensure they are tailored correctly to the audience Communication Objectives Specific, measurable, attainable, relevant, timebound Positioning Provides direction for developing messages that will most resonate with the chosen audience
3. Strategic Design cont. Key Messages Highlight the core information to be conveyed to the audiences Should be specific to the audience, reflect a specific behavioral determinant and positioning Desired behavior should be clear and achievable for the audience Strategic Approaches and ideas Reflect how the objectives will be achieved Guides development and implementation of activities Determines tools and media mix to use
Part 3: Strategic Design Audience profile, objectives, key messages and strategic approaches PRIMARY AUDIENCE 1: SEXUALLY ACTIVE WOMEN OF UNKNOWN STATUS OR WHO ARE HIV- NEGATIVE USING OR CONSIDERING USING PROGESTOGEN- ONLY INJECTABLES AUDIENCE PROFILE Example of an audience profile for woman whose HIV status is unknown Rose and her partner have started their family and have one child; she wants to wait at least three years before getting pregnant again, but hasn t spoken openly with her partner about it. She is currently using a progestogen- only injectable contraceptive to prevent pregnancy, which she obtains from the local family planning clinic. Rose and her partner want to give their children a good education and provide for them the best they can, hoping to give them more than what their own parents could give when they themselves were growing up. They have built a happy life together and feel established in their jobs and in their community, with active participation in civic and religious groups, and lots of social engagements and socializing. In fact, Rose is worried that her partner is flirtatious and she is unsure if he has occasional or ongoing relationships with other women. Neither of them has been tested for HIV and they do not talk about their potential risk. She mentioned condoms once to her partner but he did not want to talk about it. Here are some elements to keep in mind when developing this audience profile: Use of HC (considering use, current user, which method) HIV status (often unknown, possibly tested negative) Age/life stage Relationship status (short term and long- term primary or secondary relationships) Couple communication norms (e.g. on fertility desire; HIV risk behaviors; contraceptive use; condom use) Fertility desire and plans (delaying, spacing, limiting) Access to health services Social norms and networks; community participation Household status (household members, including extended family and current children; migrant family members; employment) In concentrated epidemics, female sex workers, and intravenous drug users may be a focus audience
PRIMARY AUDIENCE 1: SEXUALLY ACTIVE WOMEN OF UNKNOWN STATUS OR WHO ARE HIV- NEGATIVE USING OR CONSIDERING USING PROGESTOGEN- ONLY INJECTABLES COMMUNICATION OBJECTIVES Increase the number of women who talk with their partners about fertility desires, HIV risk avoidance, contraceptive use, and condom use. Increase the number of women and their partners who are able to make informed and voluntary decisions around contraceptive use, childbearing, and HIV prevention based on a balanced understanding of risks from unintended pregnancy and HIV infection. Increase the number of women and couples who correctly and consistently use male or female condoms, preferably in conjunction with a more effective contraceptive method, if pregnancy prevention is desired. POSITIONING Be informed. Although the risks are not clear, women and their partners need the available information to be able to make their own decisions related to HC use and HIV prevention, including condom use, based on their own life circumstances. KEY MESSAGES HIV prevention No method of contraception (except condoms) protects against sexually transmitted infections, including HIV. For HIV- negative women, there are some ways to prevent sexually- acquired HIV: o Use condoms correctly with every sexual encounter; o Encourage HIV- positive male partner who is on treatment to adhere to the ART regimen; and o Abstain from sexual relations with an HIV- infected partner(s) or partner of unknown HIV status. Partners should talk about HIV risks and about using condoms. If this is difficult, try asking a counselor, outreach worker, or friends, for tips on how to start discussions about condom use.
PRIMARY AUDIENCE 1: SEXUALLY ACTIVE WOMEN OF UNKNOWN STATUS OR WHO ARE HIV- NEGATIVE USING OR CONSIDERING USING PROGESTOGEN- ONLY INJECTABLES KEY MESSAGES Various HC methods and potential HIV acquisition Progestogen- only injectable contraceptives, such as DMPA or NET- EN, may potentially increase an HIV- negative woman s likelihood of HIV infection through sexual contact. Women/couples beginning or continuing use of progestogen- only injectablesshould also use condoms, due to the current lack of certainty regarding whether progestogen- only injectables impact the risk of HIV acquisition. Oral contraceptives (OCs) do not appear to increase the risk of HIV infection. There are currently no data available on whether other HC methods, such as implants, patches, rings or hormonal IUDs, impact susceptibility to HIV infection. Balancing risks to protect health HC methods are very effective in preventing unintended pregnancy when used consistently and correctly. Contraceptive methods can provide lifesaving benefits for mothers and infants. Balance risks of HIV infection with risks to personal health and the infant s health by unintended pregnancy, such as: o Infant death; o Maternal death; o Delivery complications; o Illness during pregnancy; and o Unsafe abortion. It is unknown whether pregnancy itself may increase a mother s chance of acquiring HIV infection.
PRIMARY AUDIENCE 1: SEXUALLY ACTIVE WOMEN OF UNKNOWN STATUS OR WHO ARE HIV- NEGATIVE USING OR CONSIDERING USING PROGESTOGEN- ONLY INJECTABLES STRATEGIC APPROACH Radio/TV Purpose: Stimulate social dialogue and couple communication Model client information- seeking and client- centered counseling Model couples starting the conversation on HIV risk, contraceptive use, pregnancy, joint decision- making ILLUSTRATIVE ACTIVITIES Integrate the key messages into existing radio/tv serial drama storylines and character conversations, especially modeling provider- client dialogue and couple communication Integrate the key messages into existing radio/tv call- in shows and Q&A with experts Print media Purpose: Increase knowledge and understanding of the potential risk of HIV acquisition with certain HC methods, HIV prevention, and balanced decision- making mhealth Purpose: Provide tailored information for client, answer specific questions depending on client s life circumstance Develop/adapt Q&A client leaflet on local clinic locations and counseling resources Develop SMS platform to provide specific information for the client, including encouraging couple communication
4. Monitoring and Evaluation Planning Helps to identify any changes that may be needed while implementing Ensure proper budget and time from the beginning How and when data will be collected and reviewed Data Sources and Indicators Process indicators Outcome indicators Using M&E Data Analyze and incorporate changes as needed throughout the length of the implementation
Illustrative M&E Indicators DATA SOURCE COLLECTION EXAMPLES EXAMPLE INDICATORS Low Resource Intensity Programmatic process sources Program- specific M&E tools developed by staff #(and%) of guidelines updated to include the issue of HC methods and potential HIV- related risks #of training curricula developed or updated #of trainings held for providers and community outreach workers %of providers trained (per facility, region, etc.) #of materials, jobs aids and client materials developed and distributed Annual progress review meetings held with MOH technical team Annual stakeholder meetings held Service statistics from clinics and providers Referral cards Registration forms Facility registers #(and%) of women receiving HC methods, by type of method and HIV status Types of HC methods available at facility Small- scale provider surveys, including community outreach worker surveys Interviews or self administered surveys given to providers #of providers who feel comfortable/confident providing counseling on HC methods and potential HIV- related risks #(and%) of trained providers who can recall key messages about HC methods and potential HIV related risks #of materials about HC methods and potential HIV- related risks distributed to women #of women receiving counseling on HC methods and potential H IV- related risks
How can we use the framework to your country s benefit? The framework is comprehensive and easy to adapt The recommended steps to follow are: 1. Understand the evidence base on HC and its link with HIV risk 2. Contextualize the evidence within wider SRH 3. Develop a country-specific communication strategy by adapting this global framework 4. Prepare for implementation
Questions? Comments!